One out of hours GP for 650,000 people

The full extent of "scandalous" gaps in the service provided by
out-of-hours doctors has been uncovered by a Daily Telegraph investigation
which has found one overnight GP on call for as many as 650,000 people.

Huge variation in coverage has been uncovered, with some areas having eight times fewer doctors on call than others with similar-sized populations.

In Barnet and Enfield, 650,000 people were covered by just one doctor overnight this weekend. In contrast, the same number of patients in Shropshire and the surrounding area had eight doctors.

It came as a separate report identified "gaping holes" in out-of-hours services and warned there could be a repeat of errors that have contributed to the death of several patients.

Experts and medical groups reacted angrily to the Daily Telegraph findings, saying that the disparity in numbers was difficult to justify. Katherine Murphy, director of the Patients' Association, described them as "absolutely scandalous".

The Conservatives have pledged to make GPs responsible for round-the-clock care.

Andrew Lansley, Shadow Health Secretary said: “We believe primary care trusts have failed to deliver the quality of out of hours services that the public have a right to expect. Labour are spending £160 million on ensuring GPs stay open for an extra hour some evenings but at nights and weekends they seem indifferent to the fact that there are hardly any doctors available at all."

Services are so stretched and understaffed that some have resorted to flying in doctors from abroad to cover shifts with questions raised about their competence and language skills.

Last week it was reported Suffolk has only two GPs on call on some nights to cover a population of more than 600000. Last weekend the county had three GPs available overnight.

This week a coroner is expected to conclude the inquest into the death of David Gray, a 70-year-old from Mania, Cambridgeshire. Gray died in February 2008 after being given a massive overdose of diamorphine by Daniel Ubani, a locum doctor from Germany who had flown in for his first out-of-hours shift.

The case has raised questions about the out of hours service, from which GPs were allowed to opt out as part of the 2004 contract changes. Responsibility instead passed to local NHS organisations.

The Daily Telegraph contacted all 152 primary care trusts in England and their out-of-hours provider to ask the number of GPs on overnight duty this weekend. Eighty-two responded, and the key findings were:

Fifteen trusts that responded left a lone doctor responsible for responding to late-night emergencies.

Two GPs were covering 530,000 people in Sheffield.

Three GPs were covering 991,464 people in Derby County and Derby City primary care trusts.

Cumbria Health on Call had seven GPs covering 500,000 people – one doctor for every 71,000 patients.

Four GPs covering 1.4m people overnight in East and North Hertfordshire PCT, West Hertfordshire PCT.

On average across England there was one GP on call for every 154,000 people between midnight and 8am this weekend.

There were also wide variations. Just four GPs are on duty overnight for the 1.4m people living in east, north and west Hertfordshire, while 11 doctors are available to the same number of people living in east, north and south Birmingham and south Staffordshire.

Five GPs respond to late night calls from the 708,000 people living in Dorset, Bournmouth and Poole, while just three doctors provide the same service to 780,000 in parts of Hampshire and Southampton.

Norman Lamb, Liberal Democrat health spokesman, said: "What the Daily Telegraph has uncovered is utterly shocking. The disparity between one area and another is hard, if not impossible, to explain or justify.

"We do not need vast numbers of doctors on call on any particular night but we do need more than what has been uncovered here."

He said attendances at A&E have risen since the new contract came into force.

Katherine Murphy, director of the Patients' Association, said: "It is such a vital service because it can be very frightening for somebody to get ill in the night, knowing that there's nobody at their doctor's surgery.

"We know from our helpline that this is a national problem. The situation is appalling and it needs to be resolved. I think these figures are absolutely scandalous."

The Primary Care Foundation, a health consultancy service which has been commissioned by the Department of Health to audit out of hours services, found "gaping holes" in services and warned that serious incidents could be repeated.

The report warned some clinicians were still unable to see notes from previous consultations even though ministers ordered this practice to stop following the case of Penny Campbell, a 41-year-old mother-of-one from north London who died after developing septicaemia following routine surgery.

She spoke to eight doctors working for the local GP out-of-hours service over a four-day Easter weekend but none of them identified the septicaemia and an inquest found this lack of diagnosis contributed to her death, in 2005.

A 2007 inquiry into her case identified major flaws in the way information was shared between doctors – many of whom did not ask to see notes made by colleagues – and said the Department of Health should act to end confusion over the role and performance of out-of-hours services.

However, a similar error contributed to the death from tonsillitis of three-year-old Joseph Seevaraj, from Hove, West Sussex. the toddler died in 2008 after a doctor ignored a local rule that patients who contacted the out-of-hours service three times with worsening symptoms should be automatically assessed.

Brighton and Hove Coroner Veronica Hamilton-Deeley said: "He needed basic medical attention. The failure to provide it was gross failure. I am satisfied there is a clear connection between this gross failure and his death."

Henry Clay, one of the authors of the Primary Care Foundation report, said such mistakes "could happen again".

The report said: "Whilst we are unsure about the legal liability of the primary care trusts and providers, we are absolutely certain that the organisations and individuals involved will be exposed to severe criticism were there to be a serious incident that arose from some of the gaping holes in the arrangements that appear to exist in a few places."

The report also warned that calls from patients that in some areas would be deemed urgent, requiring assessment by a clinician within 20 minutes, are being classed as non-urgent in some places.

The report found huge variation in levels of demand on out of hours services.

In some places there were just 50 calls for every 1,000 population where as in others the figure was as high as 225 calls per 1,000 over one year.

People in cities tended to call out of hours less often than those in rural areas, probably because there were alternatives such as walk-in centres where they could seek help.

But the report added that the variation was still 'startling' and surmised that some of the low demand may be due to poor experiences patients had when they last called the out of hours service.

In fact as the company is paid the same whether there is high or low demand for the service there may be an incentive to deter patients from returning, the report said.

The audit is due to repeated by the Primary Care Foundation with extra questions on how many out of hours shifts are unfilled and what proportion of work is carried out by local doctors.

In the Telegraph investigation, BarnDoc Healthcare, a doctor’s co-operative covering the London boroughs of Barnet and Enfield, provided the most sparse out-of-hours cover with one GP available overnight for 650,000 people. A nurse and a call handler are also available.

Alan Franey, chief executive of Barndoc, said he did not have any concerns.

“We have nurses on duty overnight who deal with quite a number of the queries that come in. But the number of home visits range from about one to six, so it's not as if there's a huge number of visits overnight,” he said.

A spokesman for NHS Enfield and NHS Barnet which pays BarnDoc said: “NHS Enfield and NHS Barnet recognise the importance of providing high quality out of hours primary care services to our patients.

"BarnDoc had an 87 per cent satisfaction rating from a survey in 2008 and the service regularly has positive feedback from patients. The number of nurse practitioners and GPs on duty reflects the demand for the service. Robust plans are in place to ensure that if the demand increases, such as during the recent flu pandemic, BarnDoc can immediately increase the number of GPs on duty.”

Shropdoc, a doctors' co-operative covering the Primary Care Trusts of Shropshire County and Telford and Wrekin as well as Powys Local Health Board, provides eight GPs overnight for a population of 600,000 people.

The doctors are in fully equipped four-wheeled-drive vehicles with phones and laptops.

David Stout, director of Primary Care Trust Network, said: “GP out of hours care is only one of the ways patients can access urgent and emergency care and PCTs will make decisions as to how best to arrange services on the basis of local conditions.

“It is far too simplistic to say that quality of care is defined by numbers of GPs and we must look at how we can improve standards while realising that a return to the old and discredited system of the past will not provide the sort of care patients of today would expect.”

A spokesman for the Department of Health said: "Primary Care Trusts have a legal obligation to ensure safe, high quality out of hours services are available to their local population.

"It is the responsibility of PCTs and their out of hours providers to assess the needs of their local population and decide the appropriate level of staffing for their area based on factors such as the time of day or night, historic demand and whether the location is urban or rural."

OUT-OF-HOURS SERVICE

About nine million patients require out-of-hours care in England each year.

Until 2004, GPs were responsible for their patients around the clock, making localised agreements to provide cover in order to ensure some time off.

It was a system that dated from the post-war creation of the NHS, and changes to modern working patterns among Britons rendered the arrangement an anachronism.

In 2004, the new contract for doctors split the responsibility between in-hours and out-of-hours care, making GPs responsible for care only between 8am and 6.30pm and it fell to primary care trusts to commission the out-of-hours service.

Nine in 10 doctors opted not to work out-of-hours, leaving it to the PCTs to employ private firms or groups of independent doctors and other health staff to provide cover.

One in three trusts struggles to find local GPs and flies in foreign doctors who are paid as much as £800 a shift to work unpopular hours.

The situation has resulted in patients struggling to get through to doctors out-of-hours at the same time as GPs’ average pay has broken through the £100,000 barrier.

In May 2006, the National Audit Office found only one in 10 trusts clinically assesses patient within 20 minutes of phone call.